All Medicaid Programs |
Obsolete Policy |
Effective July 1, 2016 - February 28, 2017 (356-2 was combined into 356 as of March 1, 2017)
What is Presumptive Eligibility?
Presumptive Eligibility (PE) allows clients to receive temporary medical assistance while the eligibility agency (The Dept. of Workforce Services-DWS) determines their eligibility for ongoing Medicaid or CHIP.
The Department of Health will designate qualified hospitals to determine Presumptive Eligibility for the following coverage groups. Hospitals may not delegate authority to determine PE eligibility to non-hospital employees. Hospitals must have a formal agreement in place with the Department of Health.
Child 0-5
Child 6-18
Pregnant Woman
Former Foster Care Individuals
Parent/Caretaker Relative
General Eligibility Requirements
To qualify for the presumptive eligibility program, a client must meet the following general requirements based on preliminary information received by qualified hospitals:
Be a U.S. citizen, qualified alien, or lawfully present child (205-2.1)
Be a Utah resident
Have a gross household income at or below the federal poverty limit for the specific PE program
Must not already be covered on Medicaid, CHIP, UPP, PCN, or approved for Medicaid with a spenddown.
Must not have received a denial for Medicaid, CHIP, UPP, or PCN within the past 30 days unless the household circumstances have changed.
There is no resource test for PE.
There is no presumptive eligibility for the medically needy coverage group.
TPL (Third Party Liability) information is not an eligibility requirement for Medicaid PE; do not deny PE for failure to provide TPL. It is optional for the client to provide TPL for Medicaid PE.
For ongoing Medicaid, TPL must be verified and referred.
Household Size
Determine the household size using the following guidelines. Include only people who live together.
Child 0-5
Applicant
Applicant’s parent(s) and step-parent(s)
Applicant’s sibling(s) and step-sibling(s) under age 19
Child 6-18
Applicant
Parent(s) and step-parent(s)
Legal spouse of applicant(s)
Applicant’s unborn child(ren)
Siblings and step-siblings under age 19
Pregnant Woman
If the pregnant woman is under age 19
Applicant
Legal spouse of applicant(s)
Applicant’s parent(s)
Applicant’s unborn child(ren)
Children including step-child(ren)
Siblings and step-siblings under age 19 if applicant is age 18 or younger